Washington DC, Artificial Cervical Disc Replacement not covered by CareFirst BlueCross BlueShield, no assistance offered by doctor.

[mccauleyjw]

Hi Everyone,

This was also posted in my introduction, but I wanted to post it under Health Insurance.
My name is John. I am 47 year old male living in Alexandria, Virginia

I am Self Employed and have CareFirst BlueCross Blueshield for my medical provider at $400/month.

I started Chiropractic treatment in 1990 for lack of natural curve in cervical spine and degeneration if disc. Treatments fairly effective in pain reduction. However, I was told at that time that surgery maybe needed in the future and it would be in my best interest to hold off as long as I can for newer technologies.

I saw Dr. Simon Fishman, in October 2010, for numbness in left arm and weak left tricep. An MRI was ordered along with EMG testing. MRI reported the following findings: Discogenic disease, resulting in central canal and bilateral neural foraminal narrowing at C5-C6 and central canal and left neural foraminal narrowing at C6-C7. Findings at C6-C7 may account for patient's left-sided radicular symptoms. EMG tests support MRI finding.

I Saw Dr. Charles J. Riedel, Neurosurgeon, Arlington Virginia in March 2011. Dr. Riedel recommended Anterior Cervical Discectomy and Fusion (ACDF) of the C-6 and C-7 or Cervical Artificial Disc Replacement. I have been informed that he has done many ACDFs, but only 10 to 20 Cervical Artificial Disc replacements using the Prestige Artificial Disc.

I would like to have an Cervical Artificial Disc Replacement. I do not want ACDF or any type of fusion. However, CareFirst BlueCross Blueshield states that Cervical Artificial Disc Replacement (procedure code 22856) is still considered experimental at not covered. Although I feel Dr. Riedel maybe a good surgeon, Dr. Riedel's staff is not willing to assist me in getting CareFirst BC/BS to approve a Cervical Artificial Disc Replacement, stating that ACDF fusion is my only choice.

I have waited nearly 20 years in pain for a newer technology and to avoid fusion. There is no doubt in my mind that Cervical Artificial Disc Replacement is much better that fusion. However, I cannot find a doctor that can help me get this procedure approved. I am worried that permanent nerve damage may occur if not treated soon.

Can anyone recommend a good surgeon in the Alexandria/Washington DC area that accepts CareFirst BlueCross Blueshield and is "Pro" Cervical Artificial Disc Replacement that will also assist in getting the procedure covered by my health insurance.

Thank You,

John

[trkdoc714]

John,

I don't have any knowledge in that area (cervical or BCBS) but I'm sure some of our Cervical patients will lend a hand.

Welcome to SPS. Sorry you have to be here but I'm glad you found us.

As far as insurance companies go, many of us have fought long, hard battles with mixed results.

Bob

[mccauleyjw]

Hi Bob,

Thanks for you thoughts and personal message. Although, my Insurance was not listed at this time. I did find some interesting info at The Spine Institute from the link you sent me. I do have an Attorney that specializes in Medical Insurance, but I need a doctor in my corner.

Basically, I feel this needs to happen.

1- Find a doctor that is "Pro" Cervical Artificial Disc replacment.

2- The Doctor submits paperwork stating that it is a medical necessity for pre-approval.

3- Most likely CareFirst declines the procedure calling it experimental.

4- My Attorney writes the appeal.

Basically, we need a doctor who is experienced in dealing with Insurance companies that consider this procedure as "Experimental". Something that I can give my Attorney to work with.

Again, thank you for your welcoming thoughts and info.

John

[Cindylou]

Welcome John, I'm sorry you are finding yourself in the predicament you are in, especially battling for insurance approval of a cervical adr. I don't want to be Debby Downer, but this is a very big, up-hill battle you have ahead of you. But I think you know that. It seems like it should be so cut and dry, you know? But the insurance companies are extremely stubborn and have been "sitting" on this "experimental" excuse for way too long. It's just ridiculous. I do hope you can get a doc in your corner who will fight for you more and I hope it's soon. I wish I had something more to offer you. Good luck! Cindylou

[mccauleyjw]

Hi Cindylou,

You are not being Debby Downer. Looking at your signature, I am sure that you are very experienced with battles with the insurnace companies and just being real. Yes, I know it is an uphill battle. Yet, I know there has to be some doctor out there that believes in the newer technology over the standard "golden fusion". Thanks for your support.

John

[Justin]

Hi Cindylou,

You are not being Debby Downer. Looking at your signature, I am sure that you are very experienced with battles with the insurnace companies and just being real. Yes, I know it is an uphill battle. Yet, I know there has to be some doctor out there that believes in the newer technology over the standard "golden fusion". Thanks for your support.

John

Hi John,

Welcome to SPS. There are many surgeons that "believe in newer technology over the standard 'golden fusion'." Unfortunately, I've spoken with many, many Spine Patients that had all of their "Is" dotted and "Ts" crossed with countless letters of medical necessity, etc. etc. and they were still denied.

Good luck...definitely do a search for other Spine Patients here at SPS and their experiences with reimbursement / insurance approval.

[laid up doc]

the DC area, in my experience, is often medically conservative. i don't know of any ortho or neurosurgeons who do lumbar ADR's in DC - you have to go to Baltimore.

Dr Joseph O'Brien at GW (spine ortho) does cervical ADR's. he's a good guy, trained at Hopkins. you may see what he has to say.

[Pbchoclovr]

You might also try Hopkins itself in Baltimore. They take Carefirst. I had fusion with them. I asked about an ADR but I'm not a candidate, but ADR is something they do.

[mccauleyjw]

Thanks Pbchoclovr and laid up doc,


I actually did travel north of Baltimore and met with Dr. Paul McAfee in Towson MD. I liked Dr. McAfee along with his staff. Due to my age, Dr. McAfee has recommended ADR of the C6-C7 and C5-C7 using the ProDisc-C.

His staff has submitted pre-approval paperwork to CareFirst BlueCross BlueShield and are willing to submit one appeal on my behalf. So, that is a step in the right direction. We expect CareFirst to deny the procedure. It is "experimental" and multi-level. Once the initial claim is denied, I have an Attorney that will work in my behalf.

Here is the strange thing. The pre-approval paperwork has surgery scheduled for tomorrow, Wednesday, September 28, 2011. Although we expect CareFirst to deny the procedure, we have not heard anything from CareFirst and that date has been cancelled.

[runagain]

John,

Welcome and good luck with your insurance company.
I just had my second ADR surgery but I had to wait a long time and go through many hoops to get the second one covered.
The first one was never covered (thus far).
I know of people who didn't stay overnight in the hospital, so they could get the ADR covered.
There are ways to get coverage.

You know the saying: There are more than two ways to skin a cat.

The fact of the matter is that cervical ADR is showing some impressive successes, under the right surgeon, people are getting good results, more so than for lumbar.
The approach is more simple and the recovery is faster than for lumbar surgeries.

Today, I was trying--again--to tell my brother why ADR is better in some cases and how Aetna is one of the insurance companies that has a positive decision for ADR and he kept telling me that it takes time for the devices to gain approval. I told him, once again, that trials for ADRs in this country go back at least eight years. He told me, "Like I told you before (sis), these type of surgeries have to have a DRG (diagnosis-related group)."

"Well," I said. "The ADRs already have a DRG".
He gets a little flustered when I spout ADR info to him. He has no clue as to how many ADRs are implanted in patients each year in the U.S.

I don't know what the number is but I do know that doctors are getting positive decisions from workers comp companies, people under government insurance (FDA-approved), certain insurances and other ways.

And I tell him and he may not be listening, "That there are several Americans each day getting ADR surgeries overseas".

One day, ADRs will be the gold standard of care. However, ADRs are not indicated in every patient. At least with the lumbar ADRs, the surgery is more technical than a run-of-the-mill fusion. There are doctors all over America that do ADRs.

I hope you get the surgery that is the best fit for you,

Take care,

Runagain